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Application <br />-FOR- <br />Certificate of Appropriateness <br />Historic Preservation Commission of South Bend & St. Joseph County <br />125 S. Lafayette Blvd., South Bend, Indiana 46601 <br />Mailing Address: County -City Building, South Bend, Indiana 46601 <br />Phone: 574 - 235 -9798 • Fax: 574 -235 -9578 • Email: SBSJCHPC @co.st josephin.us <br />Website: http:// www. stjosephcountyindiana-com /sjchp /index.html <br />OFFICE USE ONLY » »» DO NOT COMPLETE ANY ENTRIES CONIUMD IN THIS BOX » »» OFFICE USE ONLY <br />Date Received %31 Application Number a &q <br />Past Reviews X YES (Date gtlast Reaiew) .2Z -7-4 7 ❑ NO <br />Staff Approval authorized by: Title: <br />Historic Commission Review Date: 17 ._&We �i rr <br />F1 Local Landmark [ fHistoric <br />� cal Hcc District (Name) . <br />F] National Landmark n National Register District (Name) <br />Certificate of Appropriateness: <br />n Denied n Tabled n Sent To Committee n Approved and Issued <br />DATE <br />Address of Property for proposed work 1 'i G 1 • / I � <br />Street mber and Street Name � <br />Name of Property Owner(s) (Please Print) �.1 � A X 11 . 4 1,, <br />Address of Property Owner(s): Ih I �^ • 1✓L; I <br />Contractor(s) Name MA 1^ t/' <br />Contract Company Name: <br />Contractor Address: <br />City: <br />Phone: f 7y- Y f' 5 X 0'Q2_ <br />Current Use of Building: 1; • /3/ <br />(Single Family —Multi-Family —Commercial —Government — Industrial —Vacant —etc.) <br />Type of Building Construction: --a e •�` h <br />(Wood Frame — Brick -Stone — Steel — Concrete — Other) <br />Proposed Work: [] In -kind ❑ Landscape [:] New ER Replacement (not in -kind) [:] Demolition <br />(more than one box may be checked) , ll T <br />Description of Proposed Work: 9,*_ Q/,, i Id 47 f l Lv �'{ <br />1 rZY4 7 c�Z - !Uatee ar'-4 Qs, i44&& 1' '*os°eh <br />a�an C'o1kNyNS- � ACLo �4fCdt�` V'Rr <br />Owner /Contractor: e -mai 6 t/'g C_ /�u, COI !6. "Co <br />(Tlds of(rce will correspond with only one designee) J <br />and /or - <br />— APPLICATION REQUIREMENTS ARE LISTED ON REVERSE SIDE — <br />